Use of Psychotropic Medication During Lactation in Postpartum Psychiatric Patients: Results from an 8-Year Clinical Sample

Introduction

It is well known that the postpartum period may affect the course and emergence of psychiatric disorders. Mood disorders and anxiety disorders during this period are important public health issues that can lead to impairment in social, family, and occupational functions. Many postpartum patients with psychiatric disorders, especially if the symptoms are severe, need to be treated with psychotropic drugs. A general recommendation is that the risk/benefit profile of psychotropic medications in postpartum women who require pharmacological treatment should be balanced. In this context, lactation is one of the major challenges in the treatment of these patients. Owing to its invaluable source of nutrition as well as lifetime biological and psychological benefits for the infants,^1–3 many mothers and psychiatrists would like to continue breastfeeding.

Antidepressants, antipsychotics, mood stabilizers, and benzodiazepines comprise the main psychotropics used in psychiatry practice. Antidepressants and antipsychotics are generally prescribed less often for postpartum women when compared with the general population.^4,5 Epidemiological studies suggest that antidepressants, antipsychotics, and benzodiazepines are prescribed at a frequency of 0.6–5.5%, 0.30–0.38%, and 0.5%, respectively, in postpartum women in the general population.^5–8 However, similar data in a perinatal psychiatry clinic setting are currently inadequate. This study aimed to report the profile of psychotropic medications used and lactation status in a clinical sample comprising of postpartum patients.

Methods

This study was carried out on postpartum patients who were admitted to the perinatal psychiatry outpatient clinic of a university hospital between January 1, 2012 and December 31, 2019. The sample included 263 patients. The study data were obtained by reviewing clinical registers of patients with maternal age of ≥18 years. The presence of a minimum 4-week follow-up period was another inclusion criterion. Endocrine abnormalities, severe infections such as pneumonia and sepsis, cardiovascular and pulmonary system diseases, neurological disease, and severe metabolic disease in the patients or their infants were exclusion criteria.

The ethics committee of Necmettin Erbakan University, faculty of medicine, approved the study procedure. To assess sociodemographic and clinical features of the patients, a semistructured form developed by the authors was used. Psychiatric disorders were determined by means of the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (SCID-I). ⁹ The follow-up visits were carried out for a period of 1–4 weeks postpartum depending on the patient's psychiatric status. Owing to the retrospective design, the study did not lead to any interference in the clinical follow-up and treatments of the patients. Data were analyzed using the Statistical Package for the Social Sciences (SPSS), version 16.0, for Windows (SPSS, Inc., Chicago, IL). Descriptive analyses were conducted to assess demographic characteristics, use of psychotropic medications, and other clinical features of the sample.

Results

The mean age of the sample was 30.6 ± 5.1 years. Seventy-eight (29.7%) were primiparous and 185 (70.3%) women had two or more children. Almost all of the participants (99.6%) were married. The proportion of women who were employed and were educated at the University level was 14.4% (n = 38) and 21.3% (n = 56). The psychiatric diagnoses were major depression in 112 (42.6%) patients, an anxiety disorder in 169 (64.3%) patients, bipolar disorder in 26 (9.9%) patients, and schizophrenia or related psychotic disorders in 12 (4.6%) patients (Table 1). The mean follow-up period was 13.3 ± 14.7 weeks. Whereas 145 (55.1%) patients were first admitted at the postpartum period, 118 (44.9%) were followed up from their pregnancy to the postpartum period.

Psychotropic medication was administered to 242 (92.0%) patients. Table 2 shows the medications prescribed and the number of patients who used them. The most frequently prescribed medications were paroxetine and sertraline. Among antipsychotics, olanzapine and quetiapine were the most common. Ten of 13 patients who received mirtazapine and all of the 10 patients who received lorazepam used a selective serotonin reuptake inhibitor (SSRI) concurrently. A switch between antidepressants was made in 17 (6.5%) patients. These switches were as follows: from an SSRI to paroxetine (n = 7), from an SSRI to sertraline (n = 5), from an SSRI to venlafaxine (n = 2), from an SSRI to citalopram (n = 1), and from mirtazapine to amitriptyline (n = 1). There was no switch between other medications reported.

Of the 242 patients who received pharmacotherapy, 201 (83.1%) continued with breastfeeding. The remaining patients discontinued breastfeeding due to following reasons: spontaneously without patient's own decision (n = 19, 46.3%), recommendation of the psychiatrist due to the requirement of more comprehensive pharmacological treatment of the patients or safety concerns about the medication (n = 12, 29.3%), patient's own decision without any recommendation from the psychiatrist (n = 9, 22.0%), and adverse events (somnolence and tremor) due to olanzapine (n = 1, 2.4%). The 12 patients who were recommended by the psychiatrist to discontinue breastfeeding had bipolar disorder, schizophrenia, or obsessive-compulsive disorder plus major depression. Lithium quetiapine, valproate, and carbamazepine for bipolar disorder, olanzapine for bipolar disorder and schizophrenia, risperidone for schizophrenia and obsessive-compulsive disorder, and sertraline for obsessive-compulsive disorder were administered to these 12 patients (Table 2). In contrast, the proportion of continued breastfeeding in patients with a diagnosis of bipolar disorder and schizophrenia or related psychotic disorder was 50% (n = 13 and 6, respectively).

Discussion

To our knowledge, this is the first study examining the characteristics of pharmacological agents used during the postpartum period and lactation status in patients who were evaluated in a perinatal psychiatry clinic. This study presents clinical data collected for a period of 8 years, which may be useful in clinical practice.

In our sample, antidepressants were the most frequently used psychotropics. This is expected, since most of the patients had major depression or an anxiety disorder, which are clinical indications for antidepressants. A principal factor in determining the type of psychotropics prescribed in pregnant and postpartum women is the safety of medications on the fetus or infants. SSRIs are accepted as first-line antidepressants during pregnancy and the postpartum period.^10,11 Sertraline and paroxetine appear to be the most favorable SSRIs in breastfeeding patients owing to their good safety profile.^12,13 This may explain the frequent prescription of these two SSRIs to patients included in this study. Among antipsychotics, olanzapine and quetiapine are frequently prescribed for the same reason. However, somnolence and tremor may be observed in breastfed infants exposed to olanzapine. ¹⁴ Despite limited available data, quetiapine may be preferred as first-line or second-line because of its very low relative infant dose and low adverse event profile. ¹⁴ Lithium is widely used in the treatment of bipolar disorder. There is no clear evidence suggesting any contraindication to the use of this mood stabilizer in breastfeeding women; however, theoretical risks and a relatively high exposure for the infant through breast milk led to a recommendation of possible use with caution.^13,15 In our sample, lithium was stopped in seven of eight patients due to safety concerns and requirement of treatment in combination with psychotropics.

This study indicates that 83.1% of the patients continued breastfeeding while receiving psychotropic medication during the postpartum period. Although lactation continued in 50% of patients with bipolar disorder or schizophrenia, when the severity of these disorders is considered, this proportion is not low. In contrast, adverse events due to medications in the infants of patients who discontinued breastfeeding were very low. These results suggest that psychiatric patients, especially those with depression or anxiety disorder, can continue with breastfeeding during pharmacological treatment.

This study has several limitations. A retrospective design rather than a prospective systematic observation of the patients is the main limitation. However, ethical and legal concerns make prospective studies difficult in perinatal patients. In contrast, there are also naturalistic features in this study. Another major limitation is that the study was conducted in one clinical setting. Data from a single institution of a single country cannot be generalized. A short-term follow-up period is another limitation. Despite the limitations, we think that this study presents useful data for clinicians. Sertraline and paroxetine among antidepressants and olanzapine and quetiapine among antipsychotics appear to be the most frequently used psychotropic medications during the lactation period in psychiatry practice of our institution. The current results also suggest that in most patients included in this study, lactation can be continued with these pharmacological options. These results should be confirmed by further studies. Further prospective and long-term observational studies with large sample sizes may provide more comprehensive evidence for clinical practice.